In just five years, 49 states have passed laws to raise awareness about concussions and ensure proper treatment of head injuries in young athletes. The rapid spread of “return-to-play” laws came after the revelation of long-term brain damage in several former National Football League players and alarm at the local level that young athletes needed more protection and care in dealing with concussions.

In just five years, 49 states have passed laws to raise awareness about concussions and ensure proper treatment of head injuries in young athletes.

The rapid spread of “return-to-play” laws came after the revelation of long-term brain damage in several former National Football League players and alarm at the local level that young athletes needed more protection and care in dealing with concussions.

As the new laws settle into place, experts believe they are just a first step. The laws focus on education, but there are no penalties in place to ensure their effectiveness.

Meanwhile, concussions are increasing, and almost half the concussions in high school sports occur in football. But determining exactly what can and needs to be done is difficult in the shifting landscapes of sports and medical research.

Even with new laws, prevention of concussions remains elusive. Medical experts do not completely understand what takes place in the brain when it shakes, twists or stretches inside the skull.

Parents and doctors are more concerned than ever about the long-term effects of contact sports on young brains. Coaches and players must adapt in football’s play-through-pain culture as they are asked to appreciate the dangers of concussions, which may offer few physical signs initially and can vary greatly from person to person.

Greg Soehnlen was a football player at North Canton Hoover High School in Ohio who suffered his first concussion during his junior season and a second, more severe concussion during his senior season. Shortly after deciding to write his senior paper on concussions, Soehnlen was struck in the back of the head during a lacrosse scrimmage.

This third concussion ended his high school sports career and thoughts of contact sports in college. The risk of more concussions was too great.

Soehnlen's concussions brought headaches, light sensitivity, difficulty concentrating, anxiety and depression. His symptoms were worse and recovery time longer with each concussion. Researching his senior paper taught Soehnlen the worst-case scenarios of head trauma, from long-term cognitive disability to death.

Fortunately, Soehnlen received enough mental and physical rest to allow his brain to recover. He graduated in the spring and, now healed, feels like himself again.

“I’m glad I’m still me,” Soehnlen said.

For all players, that’s the goal of the new laws and ongoing medical research.

As the 2013 high school football season begins, the discussion continues on how best to protect the brains of young athletes.

INJURIES LED TO LAW

The mental deterioration of numerous former NFL players over the past decade made concussions a national topic.

High-profile players such as Mike Webster, Dave Duerson and Junior Seau were all dead by the age of 50 or younger after suffering the effects of repeated hits to the head.

Page 2 of 6 - Duerson and Seau committed suicide in 2011 and 2012, respectively. Both shot themselves in the chest to preserve their brains for study. Autopsies on many former players found chronic traumatic encephalopathy, a progressive brain damage that comes from repeated head trauma.

This type of brain damage was also found in 26-year-old Cincinnati Bengals wide receiver Chris Henry after his death in 2009 and 21-year-old University of Pennsylvania lineman Owen Thomas, who took his own life in 2010.

Neither Henry nor Thomas had any history of concussion, causing alarm about what the normal, sub-concussive banging of heads meant for younger football players. Multiple research projects in recent years have shown that sub-concussive hits take a toll on the brain, although the long-term extent of these hits is unclear.

Dr. Richard C. Cantu is a neurosurgery professor at the Boston University School of Medicine and medical director of the Sports Legacy Institute, an organization that strives to advance the study, treatment and prevention of brain trauma.

“What we know is scary as hell,” he said about research on the cumulative damage of sub-concussive hits. “That’s probably the best way to phrase it.”

Since August 2011, more than 4,000 former players have filed lawsuits accusing the NFL of withholding information on the dangers of concussions.

Zackery Lystedt brought the focus on brain damage to the high school level in 2006.

A 13-year-old football player in the state of Washington, Lystedt suffered permanent brain damage when he continued to play in a junior high game after suffering a concussion. His ordeal led to what became known as the Lystedt Law.

The law requires a youth athlete suspected of a concussion or head injury to be immediately removed from play and that a physician provides written clearance before the athlete returns. The law also requires parents and athletes to sign a concussion information sheet and mandates the creation of concussion education materials for coaches, players and parents.

Washington’s governor signed the law in May 2009, and it became the model for variations of the law passed in 48 other states. Only Mississippi has no form of concussion law.

As attention increased on the issue, so have the number of reported concussions, even as participation in high school football dropped slightly.

Dr. R. Dawn Comstock is a faculty member at Colorado University’s Pediatric Injury Prevention, Education and Research Program. She maintains the High School Reporting Information Online injury surveillance system, a database that collects injury information on prep sports across the country. According to Comstock’s data, the estimated number of concussions in high school football jumped from 55,007 in 2005-06 to 140,057 in 2011-12.

Most experts believe fewer concussions are being missed, rather than more concussions occurring. Some estimate that 50 percent of concussions still go undiagnosed, down from the estimated 80 percent in the 1990s.

Page 3 of 6 - Comstock’s data shows that among total injuries in nine major high school sports, including football, concussions accounted for 9.2 percent in 2007-08, but rose to 22.7 percent in 2011-12.

Dr. Joseph Congeni is the director of sports medicine for Akron Children’s Hospital and the team doctor for Archbishop Hoban High School’s football team.

“I think the biggest part of (concussion laws) is education,” he said, “so that people can deal with it, be aware of it and know where the resources are for the best people on the medical team to care for those with brain injuries so we’re not returning people to play too soon.”

LEGAL PROTECTIONS

The intention of the laws is to make sure another Zackery Lystedt does not happen.

While state laws vary in language, they all revolve around three key components:

• Educating coaches, parents and players on signs and symptoms of concussion;

• Removing from a game or practice any athlete who might have a concussion and not allowing the athlete to return that day;

• Requiring an injured athlete to be cleared in writing by a physician before returning to play.

The law emphasizes what medical experts say are the best ways to prevent serious injury: recognition and assessment of symptoms, followed by rest and treatment.

From the medical community to the policy makers, experts agree that the laws have been successful in grassroots education. But whether the laws provide significant protection for young athletes is unclear. Comstock just completed the first year of a three-year research project that hopes to assess the impact of the new laws.

Anecdotal evidence suggests that the laws are making a positive impact.

From 2005-09, for example, a survey found that 16 percent of athletes who lost consciousness during a game returned to play that same day. Today, research shows that less than 2 percent of football players who suffer a concussion return the same day.

According to the National Center for Catastrophic Sports Injury Research, 2012 was the first year since 1990 in which no fatalities were directly attributed to playing football at the youth, high school and college levels.

But experts believe the laws constitute a first step, not a final answer.

The laws do not include penalties for failure to comply with the new regulations by coaches, school officials and medical workers. They do not require a minimum or standard level of medical resources at games or practices. They do not have provisions to ensure the effectiveness of the required brain injury education.

“You might consider these laws to be a low-cost, partial solution to a large public health problem,” said Hosea H. Harvey, a professor of law at Temple University, referring to traumatic brain injuries (TBIs) in youth sports.

Page 4 of 6 - Harvey questions if it was wise for all states to follow the Lystedt model without evidence the law reduced the danger of youth TBIs. He believes NFL support for the new laws drove their rapid spread.

NFL commissioner Roger Goodell came out in support of concussion laws a year after Washington and seven other states passed them. He set a national goal of 10 states for passage in 2011. Twenty-four passed concussion laws that year.

Jeff Miller, the NFL’s senior vice president of public affairs, acknowledged that the league helped organize sports medicine and local advocacy groups in each state. But he believes the testimony of parents and student athletes who have dealt with concussions had the greatest effect on lawmakers.

Cantu at Boston University believes there needs to be more checking into the qualifications of physicians who decide when a player returns to action. He also believes some form of testing or other evaluation is needed to confirm that those who watch brain injury training are actually learning the material. Sitting through an online video typically is all the laws require.

“The laws are good, but the laws need to be funded so they can be carried out in a meaningful way,” Cantu said. “That costs dollars, and that’s dollars that none of the states have put forward to those laws.”

SEEKING MORE PROTECTIONS

Medical and sports officials close to high school football have a number of suggestions for better protection of players. Whether they are implemented is likely a function of politics and money.

One idea is that every high school sports program should have an athletic trainer. An athletic trainer is someone specifically trained to provide early assessment and treatment of sports injuries, including concussion.

Jim Thornton, president of the National Athletic Trainers Association, estimates that slightly more than half of U.S. high schools have access to an athletic trainer.

“The excuse is budget, but it’s frustrating,” Thornton said. “We’re relying on coaches during the heat of battle, who may have ulterior motives for leaving a kid in a game, making decisions about their healthcare.”

Some coaches believe concussion laws are an overreaction in a violent game played by increasingly bigger, faster and stronger players.

Research shows that the presence of athletic trainers in a school sports program mean more concussions are diagnosed than in schools without them. Without athletic trainers, the worry is many athletes are playing with concussions but they and their coaches don’t know it.

Cantu is one of many experts hoping for a clear diagnostic tool to detect concussion.

“What we desperately need is a financially feasible marker of brain injury, an imaging study that’s not a research tool, ... and see whether or not we can pick up these injuries even in asymptomatic people,” he said.

Page 5 of 6 - Such a tool would remove much of the guesswork involved with diagnosing concussions. Diagnosis often requires honest answers from players who have been brought up in a culture of gritting their teeth and playing through pain.

“A lot of people think kids aren’t as tough as they used to be,” said Vic Whiting, head football coach of Canal Fulton Northwest High School in Ohio. “Maybe they’re playing Xbox too much and not outside enough doing things like they used to. But as far as wanting to win and when it’s game time trying to stay in at all costs, these kids still do that. You can’t listen to them.”

To Whiting’s point, a recent survey of 120 high school football players in the Cincinnati area revealed that 53 percent of them would “always or sometimes continue to play with a headache sustained from an injury” despite knowing the risks that come with concussions.

“Extremity injuries we can live with a little bit. Shoulders and knees, we can fix a lot of those,” said Congeni at Akron Children’s Hospital. “Significant injuries to the brain you can’t fix.”

The best potential area for prevention is limiting exposure to head trauma. Players absorb roughly 2,000 hits to the head in practices and games during a season. Several organizations, from the NFL to Pop Warner, have limited full-contact practices.

Rule changes will continue to be considered, with much attention likely paid to the kickoff since the highest incidence of severe injuries occurs then.

No equipment prevents concussions as of now. Earlier this year, a Colorado jury ruled against helmet manufacturer Riddell in an $11.5 million lawsuit over injuries suffered by a teenage football player in 2008. The jury found that Riddell was negligent in failing to warn users of concussion dangers.

Dr. Henry Feuer is co-director for the Indiana Sports Concussion Network and a neurosurgeon who has worked the sidelines for Indiana University and the Indianapolis Colts.

“There is no helmet that stops that shaking of the brain,” Feuer said. “Your brain is like a little hardened Jell-O inside your skull, and when you get hit it bounces around.”

Several researchers have used accelerometers in helmets to measure the force and number of impacts players absorb. This could lead to individual “hit” counts being tracked, similar to pitch counts in baseball. As of now, that technology is simply too expensive for widespread use.

MORE PROTECTIONS UNCERTAIN

The wave of new concussion laws clearly helped raise awareness of the dangers of concussions in high school football.

But whether parents, school districts and those who govern high school sports will take more steps to require certain levels of care, new rules or different equipment remains to be seen.

Page 6 of 6 - Some high school coaches feel that concussion laws are an overreaction to a problem primarily at the professional level. Research about the cumulative impact of hits to the head for youth athletes is mounting but still inconclusive.

That leaves parents in a difficult position. They want to protect their children. They also value the character and confidence-building experience of the country’s most popular sport on their children.

Professor Harvey at Temple University does not see more immediate action on the horizon.

“If you were to look out there in the law landscape for what’s coming next, as far as I can tell right now, zero,” Harvey said. “Because all the other things you would do have complicated constituencies standing behind them, and we do not have universal agreement.”